Wrestling With Implicit Bias to Deliver Better Care for Our Patients

I appreciate the engagement by Today’s Wound Clinic on the important issue of social determinants and how they impact wound management. I am grateful that this topic is now getting the attention that it deserves in wound care, as well as the general medical community. The topic is complex and there is a lot to discuss.

Dr. Windy Cole’s recent TWC article regarding on the social determinants of wound management cites socioeconomic status and educational level as being the “top two biggest social determinants.” She comments that the two are invariably linked and that “the lower your educational level, probably the less likely you are to have a job that pays a significant amount or offers you insurance.” She suggests that we focus on patient-centered factors when addressing what physicians should consider with patients who may have health care disparities. Although educational level and socioeconomic status may be important factors, it seems ironic to mention these two variables in the absence of a discussion about implicit bias as a potential barrier to effective health care.

What is implicit bias? Implicit bias is an unintentional projection of perceptions, which may impact behavior, judgment, expectations, and health care delivery. An individual’s culture and personal experiences may influence thought patterns and mannerisms. Implicit bias may be negative, positive, or bidirectional.

As an example, I experienced a negative interaction with a physician when I sought care following a car accident. I had not disclosed that I was a physician. I was not working at the time, and my status was listed as “unemployed.” The doctor was brusque and rude to me. However, as soon as I told him of my educational level, his behavior toward me changed. I wondered, had he previously thought I was an unemployed drug-seeker? Was it my socioeconomic status that changed his perception of me? Was his new disposition toward me based upon my Ivy League status? Is favoritism now a positive bias? Neither I, nor anyone, should need to brandish a curriculum vitae on their forehead, or undergo a wallet biopsy in order to receive respectful care. 

Race is commonly associated with stereotyped pre-judgments; however, other factors that trigger bias can include age, physical appearance, beauty, weight, and gender identity.

How do these images affect your impression? Do you honestly treat everyone equally? If you believe that a patient has a lower socioeconomic status will you offer the same plan of care that you would have to a patient without those factors? I remember an emergency room attendant who would perform a tattoo count as a gauge of one’s character. If a person had three or more tattoos, disparaging remarks were made.

For those employed by a health care entity, included in the orientation process are educational modules concerning codes of conduct. I daresay that each of us remembers the video-based sessions that teach us about business integrity, diversity, equity, inclusion, and bias.

We complete our training by selecting the correct responses that we know will enable us to “pass” the exams. However, do we truly practice what is expected of us? We must enhance the relationships with others by being more aware of our own prejudices. We can individualize the plan of care and bridge the understanding by asking the patient, “What concerns you the most?”

If we can identify the patient’s primary concern, we will accomplish several things. Firstly, we are giving the patient the opportunity to voice the issues that worry them the most. Secondly, we are validating their presence and empowering their self-awareness. Thirdly, we are enhancing the relationship with the patient by creating a collaborative partnership. Moreover, we may gain insight into those other social determinants, meaning other potential barriers to care (ie, food insecurity, lack of transportation, etc.). The detrimental effects of implicit bias can lead to unequal care, health disparities, and poor outcomes.¹

I’ve observed institutional changes that incorporate policies and practices to broaden the awareness of diverse perspectives. For some, bias remains a sensitive issue, and some people are reluctant to admit to the need for introspection. However, to mitigate the ill effects of bias, everyone must first acknowledge that it exists.

Dr. Monique L. Abner is a Medical Director of Utilization Management for Amerihealth Caritas. She is the owner of Abner Advisory LLC, which focuses on healthcare awareness and patient advocacy.

Click here to download a PDF of this article.

Reference
1. Hall WJ, Chapman MV, Lee KM, et al. Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: a systematic review. Am J Public Health. 2015; 105(12):e60–76.